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Mr. Xiyuan, whose place of origin is unknown, once treated a sixty-two-year-old woman suffering from continuous metrorrhagia (uterine bleeding). He first prescribed four doses of Huanglian Jiedu Tang (Coptis Decoction to Relieve Toxicity), followed by six doses of Liangge San (Cooling the Chest Powder) combined with Siwu Tang (Four Substance Decoction), after which she recovered. This patient’s condition was caused by excessive grief, which led to tension in the Heart system, elevation of the Lung lobes, obstruction of the Upper Jiao, and accumulation of heat in the Middle Jiao, causing blood to rush and resulting in metrorrhagia; hence the treatment was effective.

Yu Zhen commented: This illustrates the treatment method for metrorrhagia due to Blood-Heat. However, if metrorrhagia results from excessive grief damaging the Lungs and Heart, leading to a sudden deficiency of Yuan Qi (Original Qi), one should use Ren Shen (Ginseng Root), such as in Guipi Tang (Restore the Spleen Decoction). Liangge San must absolutely not be used. Differentiation must be based on the pulse.

Wang Ruyan treated a woman suffering from Tai Lou (threatened miscarriage with spotting). Suddenly, she experienced severe metrorrhagia and fainted. After consuming child’s urine (Tong Bian), she regained consciousness, but fainted again shortly after. Emergency administration of Jing Jie (Schizonepeta Twig) resulted in alternating consciousness and fainting. Hemostatic and anti-fainting medications were ineffective. She suddenly began vomiting. Wang Ruyan surmised that the child’s urine and medicinal decoction had filled the chest and diaphragm, so he induced vomiting by probing the throat with his hand. Eventually, food and vegetable matter were expelled. Upon inquiry, the patient stated she had become angry after a meal, after which the bleeding started uncontrollably. He realized that fullness of the stomach obstructed Stomach Qi, causing severe bleeding. After massive blood loss, Stomach Qi became further deficient and unable to transform and transport, explaining why bleeding and fainting persisted despite blood-regulating herbs. The priority should be regulating the Spleen and Stomach. He prescribed Bai Zhu (Atractylodes Macrocephala Rhizome) 5 qian, Chen Pi (Citrus Reticulata Peel) and Mai Ya (Hordeum Vulgare Sprout) 2 qian each, decocted in water. After one dose, fainting ceased; after the second, bleeding stopped. Subsequently, he administered more than ten doses of formulas specifically for regulating the Spleen and Stomach until Stomach Qi recovered, then added blood-nourishing herbs to stabilize the condition. If one fails to examine for food stagnation and uses only hemostatic herbs for metrorrhagia and fainting, how could this not be a mistake?

Yu Zhen commented: This case is similar to "Shi Zhong" (stroke-like symptoms caused by dietary indiscretion). Thus, treating symptoms without investigating their origin is most likely to cause errors.

Gui Dahua’s wife suffered from metrorrhagia, confusion, fever, and insomnia. Some suggested it was reckless bleeding due to Blood-Heat and administered cold-natured drugs, worsening the condition. Others suggested injury related to conception and administered hemostatics, also without effect. They then invited Lizhai for consultation. He said, “This is Spleen-Qi deficiency and weakness, failing to control and contain the blood. The method should be to tonify the Spleen, and the blood will stop naturally.” He used Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with Pao Jiang (Prepared Ginger Rhizome). After a few doses, there was improvement. However, she still slept little throughout the night and experienced palpitations and fright. Babawu Tang (Eight Substance Decoction) was even less effective. Consulting other physicians, they deemed the prescription too mixed. Finally, he prescribed Guipi Tang (Restore the Spleen Decoction) with Pao Jiang to tonify the Heart and Spleen, restoring her health.

Yu Zhen commented: Babawu Tang also tonifies both Qi and Blood but was criticized for being mixed because it contained too many blood-regulating herbs and did not focus primarily on the Heart and Spleen. This shows that medication must correspond precisely to the syndrome; no compromise is acceptable.

Jiang Rujié treated the wife of Ye Tingjie. In the tenth month, she suffered from numbness whenever her eyes closed, to the point where she dared not sleep. After changing doctors repeatedly, she gradually developed metrorrhagia. Jiang Rujié palpated the left hand’s three positions: slightly wiry on superficial pressure, slightly large and forceless on deep pressure. The right hand’s three positions were large and forceless on both superficial and deep pressure. The Classic states: “Blood deficiency presents with a large pulse like a scallion tube.” It also states: “Large and forceless indicates Blood deficiency.” Furthermore: “All wiry pulses indicate fluid retention,” and “Wiry indicates劳损 (chronic strain/deficiency).” Observing the pulse and symptoms, it appeared that dual deficiency of Qi and Blood led to impaired Qi circulation, causing numbness. Contemporary physicians failed to understand this and treated it as Fire, using too many cold-natured herbs, damaging the Spleen and Stomach, causing Yang Qi to sink and resulting in metrorrhagia. From the perspective of annual cosmic movements (Si Tian Yun Qi), this year Tian Chong governs the movement, with Wind Wood in the Earthly Branch position. The combination of Wood overcomes Spleen Earth, causing Earth Qi to sink and act according to Autumn/Winter patterns. Regarding seasonal timing, from Minor Snow to Major Snow (over sixty days), Solar Cold Water governs, with Jue Yin Wind Wood as the guest qi overlaying it, creating excess Water and Fire. The Classic says: “When extreme, victory occurs without return.” With such great Spleen deficiency, how could heavy bleeding not occur? Moreover, the Spleen contains blood; when Spleen is deficient, blood does not return to its vessels and flows recklessly. The treatment should prioritize greatly tonifying the Spleen Meridian, followed by tonifying Qi and dispelling dampness, leading to gradual recovery. He prescribed Ren Shen (Ginseng Root) 3 qian, Huang Qi (Astragalus Membranaceus Root) 2 qian, Gan Cao (Licorice Root) 4 fen, Fang Feng (Saposhnikovia Root) and Jing Jie (Schizonepeta Twig) and Bai Zhu (Atractylodes Macrocephala Rhizome) 1 qian each, Chen Pi (Citrus Reticulata Peel) 8 fen. Decocted in water, taken far from meals. One dose divided into three servings. After a few doses, she stabilized.

Yu Zhen commented: A large and forceless pulse is definitive evidence of Qi deficiency; how can it be designated as Blood deficiency? Numbness belongs to Qi deficiency, a established principle of ancient sages. When Qi deficiency fails to control blood, metrorrhagia occurs; Ren Shen and Huang Qi are essential. The slight wiriness on superficial pressure of the left hand suggests Wind pathogen, so adding Jing Jie and Fang Feng is appropriate. However, the discussion is somewhat verbose, borrowing Si Tian Yun Qi theories to exaggerate the argument, making it feel broad.

Yi Silan treated a woman with metrorrhagia who had lost a tremendous amount of blood. Hemostatic herbs worsened the bleeding. She lay in bed for over a month, emaciated with poor appetite, blue complexion, black nails, shortness of breath, and phlegm-wheezing. Yi Silan palpated: Heart pulse peaceful; Liver pulse wiry-large with occasional intermission; Lung pulse deep, large, and forceful; Spleen-Stomach pulse deep and choppy; both Chi (Kidney) positions deep and forceless. He said, “This is Qi Stagnation syndrome.” Inquiry confirmed it was caused by anger. He used Xiang Fu (Cyperus Rotundus Rhizome), Wu Yao (Lindera Root), and Su Geng (Perilla Stem) as Sovereign herbs; Fu Xiong (Ligusticum Chuanxiong Rhizome) and Bai Zhi (Angelica Dahurica Root) as Minister herbs; Dang Gui (Angelica Sinensis Root), Bai Zhu (Atractylodes Macrocephala Rhizome), Shen Qu (Massa Fermentata Medicamentosa), and Gan Cao (Licorice Root) as Assistant and Envoy herbs. After taking the medicine, she immediately felt refreshed, and symptoms halved. The family rejoiced. Yi Silan said, “Not yet. At Zi hour (11 PM–1 AM) tomorrow, when the fingernails turn peach-red, rescue is possible.” At that time, the nail color indeed turned red. Re-palpation showed the left three positions unchanged, Lung pulse slightly rising, Spleen-Stomach pulse deep-slow but not choppy, Chi positions unchanged. He told the family, “At Wu hour (11 AM–1 PM), heavy bleeding will occur. Do not panic or startle the patient.” At that time, several purple-black blood clots were passed, and bleeding stopped thereafter. Someone asked, “Metrorrhagia is a Blood disorder; others failed with Blood herbs, but you succeeded with Qi herbs. Why?” Yi Silan said, “Although metrorrhagia involves Blood, its source is Qi. Qi is like a bellows; Blood is like waves. Blood follows Qi. To treat Blood, first regulate Qi. Yet some cases resolve with Qi regulation alone, while others resolve with Blood treatment without Qi regulation. Why? Because the etiology differs. Some diseases originate in Blood affecting Qi; others originate in Qi affecting Blood. By differentiating via pulse and symptoms, the sequence of treatment is determined. For example, those with congenital Blood deficiency often have vigorous Qi, presenting with coughing blood, tidal fever, sore throat, etc.; here, Blood is primary, treated with Yin-nourishing and Fire-descending formulas. This case occurred in Autumn; the Lung pulse should be floating-short but is instead deep-large, violating seasonal norms. It is said, ‘If the pulse is deep at onset, know it is Qi.’ Large indicates Fire; excess Qi is Fire. Deep and large indicates Qi stagnation and failure to circulate. Furthermore, Liver Wood in Autumn should present as weak-small; here it is wiry-large with intermission. Intermission in Liver pulse indicates Blood accumulation internally. The etiology is Liver Fire anger stagnation, causing blood to leave its vessels and flow recklessly—is this not Qi disease affecting Blood? Hence, treating Qi is prioritized.” Someone asked, “The nails were black; you predicted redness at Zi hour when bleeding stopped; you predicted recurrence at Wu hour. Why?” Yi Silan said, “This is the subtlety of Yin-Yang growth. Active Blood is red; coagulated Blood is black. Black nails indicate coagulated, un-dispersed Blood. Now, using Qi-moving herbs, at Zi hour when Yang Qi first moves, Qi movement activates Blood, so black nails turn red. At Wu hour, Yin Qi regenerates. Liver is Yi Wood, born at Wu hour. When Liver Qi receives the mandate, pathogens cannot remain, so accumulated blood is expelled at this time. Once expelled, Qi circulates Blood, cycling through meridians, curing the disease.”

Yu Zhen commented: This case’s discussion is fluent and insightful. However, it is impossible that opening stagnation and moving Qi would disperse stasis and stop new bleeding in just one dose. This merely reflects the theoretical logic of the disease; preserving the explanation serves to warn future practitioners against blindly adhering to the single method of “treating blood for blood disorders.”

Sun Dongsu treated the daughter-in-law of Pan Jingzhai. Irregular menstruation was treated with fetal-calming agents. Seven months later, menstruation suddenly became profuse, passing one or two buckets of blood clots and membranes the size of a hand. She suffered from dizziness, confusion, exhaustion. Pulse: Right Guan position large-slipping; Left Cun position large-rapid; both Chi positions large-large. Symptoms manifested at midnight: teeth grinding, confused speech, hot palms, locked jaw, cold extremities, chest distension and discomfort, blue complexion. All physicians deemed it incurable. Sun Dongsu said, “Do not fear. This is turbid phlegm flowing and stagnating in the Sea of Blood, exacerbated by mistaken fetal-calming agents. Massive blood loss leaves the Spirit without foundation; phlegm confuses the Heart orifice, causing confusion and erratic speech. Manifestation at midnight is due to Phlegm-Heat in the Pericardium and Gallbladder meridians. Regulate Qi, open phlegm, calm Spirit, nourish Blood, and she will survive.” He prescribed Wendan Tang (Warm the Gallbladder Decoction) plus Shi Chang Pu (Acorus Tatarinowii Rhizome), Jiu Qin (Wine-processed Scutellaria Root), Tian Ma (Gastrodia Elata Rhizome), Suan Zao Ren (Ziziphus Spinosa Seed), and Dan Shen (Salvia Miltiorrhiza Root). That night, during Zi-Chou hours, teeth grinding and confused speech halved. The next day, same prescription with Zhu Ru (Bambusa Textilis Caulis) increased to 5 qian per dose. Before sleep, several pills of Hei Hu Dan (Black Tiger Pill) were given. All symptoms resolved, and she recovered.

Yu Zhen commented: This case did not use the method of tonifying Qi after massive blood loss; the pulse examination and symptom assessment were excellent. However, the focus was on dizziness, confusion, and distension, not on persistent bleeding. Using 5 qian of Zhu Ru in Wendan Tang is suitable for acute illness. The root cause is Phlegm-Fire; mistaken astringent tonics caused metrorrhagia, unlike chronic non-healing metrorrhagia. Consider Madam Qian, Inspector of my county, who suffered metrorrhagia for three years. Famous physicians gathered, trying all medicines. Later, hundreds of doses of Guipi Tang and countless Ren Shen were used, with temporary relief followed by recurrence, ultimately leading to death. Even if Master Sun were present, what could he do?

Shi Lizé treated the wife of Mr. Qi Wan. Metrorrhagia did not respond to Di Yu (Sanguisorba Root) and Xu Duan (Dipsacus Root). Shi Lizé palpated a deep and knotted pulse, stating, “This is Blood Stasis syndrome.” Caused by anger during menarche. Mr. Qi confirmed, “Yes, anger stopped menstruation; half a month later, metrorrhagia began, lasting a month.” He used Tao Ren (Prunus Persica Seed) and Da Huang (Rhubarb Root) to move blood and break stasis. Someone questioned whether purgatives were appropriate after blood loss, arguing it might drain vital energy. Shi Lizé said, “Blood stagnates with Qi; accumulation does not disperse, blocking the tunnels, overflowing and flowing recklessly. Removing blockage and stagnation allows blood to return to its vessels. Otherwise, treating the branch while ignoring the root is like damming a river upstream.” After two doses of decoction, blood was passed, and menstruation resumed.

[Appendix] Gao Gugeng treated postpartum lochia不尽 (incomplete expulsion). On the sixth or seventh day, fresh blood gushed forth, accompanied by fever, thirst, hypochondriac pain, and manic screaming. Blood-nourishing and Liver-clearing blood-moving herbs were ineffective. Gao Gugeng palpated a large-rapid pulse, saying, “Lochia remains, lodged in the Sea of Blood. Newly formed blood loses its original path. Without removing stasis and promoting flow, abnormal bleeding becomes routine. How to control it?” He used Vine-processed Da Huang (Rhubarb Root) 1 liang, Sheng Di Huang (Rehmannia Glutinosa Root) 1 liang, Tao Ren paste 5 qian, Gan Xi (Cryptomeria Wood) 3 qian, decocted strongly and drunk. Someone asked, “Postpartum is severely deficient; is such strong medication not too harsh?” Gao Gugeng said, “What leaves leaves; what generates generates. Where is the deficiency?” After ingestion, several sheng of black blood clots were passed. All symptoms vanished. Subsequently, Buzhong Yiqi Tang was used for regulation, leading to recovery.

Yu Zhen commented: These two cases are identical in nature, both representing Excess syndromes. Excess syndromes are easy to treat; one attack cures them. Deficiency syndromes are difficult to cure; repeated tonification yields no merit. The Classic says, “If one cannot treat deficiency, what need to ask about the rest?” This shows that one who can treat deficiency faces no difficulties. Tonifying deficiency is a general method. One must examine the Zang-Fu organs, meridians, and extraordinary vessels to locate the deficiency and check for concurrent Cold, Heat, Dampness, or Wind. Careful differentiation may yield partial or full efficacy. Those who succeed are capable; those who fail are not. Ancient masters had established formulas for Cold, Heat, Dampness, and Wind, but Wind is often overlooked today. The Inner Classic states, “Sudden violent wind causes menstrual waters to surge and rise,” contrasting with summer heat causing boiling overflow. Thus, ancients treated Wind entering the Uterus with formulas like Yi Wei Fang Feng Wan (One-Ingredient Saposhnikovia Pill) and Ju Qing Gu Bai San. However, internal stirring of Liver Wind was rarely addressed. Liver belongs to Wind-Wood, governs Blood storage, and anger or depression cause this disease. Xiaoyao San (Free and Easy Wanderer Powder), Hu Qian Wan (Tiger Crouching Pill), Wu Mei Wan (Mume Pill), and Bugan Tang (Nourish Liver Decoction) should be used with modification. Liver Wind stirring Blood may involve concurrent Cold, Heat, or Stasis. Ren Shen, Shu Di Huang, E Jiao, Huang Lian, Di Yu, Gui Zhi, Fu Zi, Tao Ren, Bai Zi Ren, San Qi, Yu Jin, etc., can be incorporated based on pulse and symptoms. Ultimately, clinical flexibility is required; one must not view it solely as deficiency.